Shweta Subramani 0:03
Welcome everyone to the therapy insights resource roadmap show where we learn how to use the resources inside the Access Pass. If you’re subscribed to our resource library, then you have an instant access to all these resources that we’re going to be talking about today. If you’re not a member, you can get started today by heading to therapyinsights.com. If you’re listening to this episode on a podcast or watching the video on YouTube, and you want to official CEU credit, they had to therapyinsights.com and click on see us. Fill out the form for the PT resource roadmap Show Episode Number two, when you get your certificate of completion. I’m your host Shweta. We also have our therapy insights writers Ross and Troy with us today. Hey everyone. Yeah, hey. So real quick, before we get started, I would like to talk about our disclosures. Since this is being offered for CEUs, we need to verbalize our disclosures. All of us here are being paid, by Therapy insights to run the show. So let’s get started. We have a great lineup of resources this month from tips for keeping your cartilage Healthy, Heart Rate Variability monitoring, to Ankle Brachial Index and Symptoms and Differentiation of Leg pain. Let’s get started with our first resource. So the first resource that we’re going to dive into today is tips for keeping your cartilage healthy. And this resource was produced by Ross. So I will let Ross talk about it a little bit.
Ross Eckstein 1:45
Yeah. So in my practice, we see a lot of people with hip and knee arthritis. And so I thought it would be useful both for myself and for other clinicians to have kind of an educational handout that can be given at the first visit for people who come in with knee or hip pain, kind of talking about what osteoarthritis is, and some tips and strategies for keeping your cartilage healthy. So it talks about how maintaining a healthy weight is important. And it talks about some statistics like how people with the BMI over 30 have about a doubled risk of developing arthritis compared to people with a BMI that’s normal. And talks a little bit about, it’s not really supposed to be prescriptive for weight loss, but it talks a little bit about some targets that you could shoot for is as far as like 0.25% of your body weight per week, which is about a half pound for a 200 pound person, which is very achievable, and how that has been shown to be beneficial for people with osteoarthritis. And it talks about the role of diets with that and how it might be helpful to talk with a dietitian or other health care provider to get started with that. And then it talks about how losing weight in general, whether it’s through low carb dieting or low fat diet in both can be effective for losing weight. touches a little bit on inflammation. It talks about how there are some pro inflammatory cells with knee arthritis.
Ross Eckstein 3:36
In general, the focus of this piece was on osteoarthritis, but I also touched a little bit on rheumatoid arthritis and the inflammation that you see. And osteoarthritis is typically kind of a milder low grade inflammation, whereas with rheumatoid arthritis is a high grade, more severe inflammation. And talk a little bit about that and how losing weight in general reduces systemic inflammation and how that can be helpful. And then I touched a little bit on anti inflammatory diets, and how the research right now for osteoarthritis is kind of inconclusive for anti inflammatory diets. But there is stronger evidence for anti inflammatory diets being helpful with rheumatoid arthritis. And it might be just because rheumatoid arthritis is characterized by higher levels of inflammation compared to osteoarthritis. So it kind of just touches on that. And again, it’s not prescriptive, but it’s something that someone could read and could maybe open their minds to treatment going down that avenue there. And then it talks a little bit about exercise and how if you’re able to walk even walking, referenced a study that found that people who walked frequently had less severe joint space narrowing as they age compared to people who did not and so give some simple tips for that and how you can use trekking poles if you have pain with with walking and then it talks with little bit about strengthening and how that can be helpful, especially for knee arthritis in the role of quad strengthening being helpful for that. So yeah, that’s pretty much the piece, it’s kind of has some tidbits that can be useful for clinicians as well. But really, it’s something to kind of reinforce what we say in clinic because a lot of times we tell patients things, and I think having that handout that reinforces what you say, might help with buy in. So that’s kind of what this handout is for.
Shweta Subramani 5:33
Cool, thank you, Ross. All right. Our next resource is an article this was also produced by Ross about Blueberries improving Pain, Gait performance and Inflammation in Individuals with Symptomatic Knee Osteoarthritis.
Ross Eckstein 5:50
Yeah, so this study was kind of in line, I guess, with that piece that I just talked about. So essentially, this is a study where they looked at they used freeze dried berries, I can’t remember the dose, right, oh, 40 grams of freeze dried berries, which is not a particularly large dose of berries. And how in this study, there were some positive effects on pain and gait performance. And this was compared to a placebo, which I believe was some sort of sugar, maltodextrin. And so it’s possible since that’s proinflammatory, theoretically, you know, that might confound your results a little bit. But I thought it’s something you know, telling people that they could have some blueberries is probably not going to hurt them and for most people, and so I thought it was kind of a cool study that something that might be beneficial for people with arthritis.
Shweta Subramani 6:56
Ross I was I was actually curious, like, when they say that their differences, there weren’t really significant differences between groups, but rather within groups, I’m curious, like, what exactly are they mean by that? Like, did they even with like, maltodextrin, like some of the placebo group, people did not really show effects. And some really showed drastic effects, like what was going on there, exactly?
Ross Eckstein 7:21
You know some of that could be due to effect sizes, as you touched on. And some of that could also be, I can’t remember what the sample size was with the study, I don’t think it was incredibly large. And sometimes you need a larger sample size to see those between group differences when you can see them within groups with a smaller sample size. Again, I don’t remember exactly how many people were in this study. But I suspect that that might have been part of the reason why you wouldn’t see those between group differences as easily as you would see the within group differences.
Shweta Subramani 7:53
Yeah, I think it sounds really interesting. Like I never really heard about, like blueberries impacting osteoarthritis. So that would be something that, you know, you could possibly have your patients try.
Ross Eckstein 8:05
Yeah, yeah, that’s something that’s simple. And, you know, probably not going to hurt them as the way I see it. Absolutely.
Shweta Subramani 8:14
Okay, our third resource is How and When to Calculate Ankle Brachial Index, and it’s by was produced byTroy so I’m gonna have Troy talk about it a little bit.
Troy Adam 8:28
Yeah, great. Thanks. Thanks for bringing me on. So yeah, this piece is really talking a lot about Ankle Brachial Index. And if you haven’t heard of that before, it’s really a relationship between your blood pressure’s specifically your systolic blood pressure, right? So that that higher number that we often report when we’re taking taking pressures, it’s the relationship between the pressure in the upper extremity and the pressure distally in the lower extremity. So why do we really care is it can be indicative of a couple of different pathologies, primarily like peripheral vascular disease would be the number one thing that you’d be watching for here. So once you do I mean, I guess ultimately, I guess how I see this resource really being used and managed in the clinic and this is one of my favorite types of resources.
Troy Adam 9:19
First off, which is this is something that it’s got a direction sheet on it. So you know, I don’t calculate Ankle Brachial Index all that often. Right. So when I do it, it’s like it’s nice to have a sheet there for me, that’s really what this first page is about. And then the second page which is also super nice, is that’s what I just fill out and I put it in in into my you know, documentation and have them scan it straight into into medical records, which is really convenient. You print off a second copy if you wanted to send send your patient home with one or send your patient to the physician with one after the fact. If you’re if you’re worried about it, but Um, so the first page really talks a lot about kind of who’s at risk for issues with Ankle Brachial Index. So it lists off some different kinds of comorbidities and and risk factors, I guess associated with that. But how you actually perform that performance measure, it’s not overly complicated. The one the one limiter that I feel like a lot of folks have is maybe access to a Doppler, right, which is, you know, an auditory way to really Yeah, kind of measure pulse. So right, normally, we would, we would, you know, be listening in with our stethoscopes to hear blood pressures. In this case, we you know, put in headphones, or you just have it set to, to make kind of noise in the clinic. And you can hear the blood kind of whooshing, past this, this Doppler.
Troy Adam 10:53
So you’re going to have your patient come in, if you’re concerned about this, or trying to screen for PVD, you’re going to have them come in take their take their blood pressure in both arms, they should be the same. In general, they’re within about 10 systolic blood pressure should be about within 10 millimeters of mercury from one side to the other. But you’re going to, you’re going to record their highest value on either the right or their left side. And then and then you’re going to, you’re going to lay them down. Normally, this is where you actually will take the pressures you in the ankle, and you put that same blood pressure cuff around somebody’s around somebody’s foot or just just proximal to the ankle, occlude blood flow, and you’re going to listen to the dorsalis pedis artery, as well as the tibial artery, which, you know, on the sheet kind of gives you an idea of where to palpate those, if you’re unfamiliar, they’re, they’re, you know, they’re somewhat sometimes they’re a little bit more challenging. But yeah, occlude blood flow, listen in with that Doppler, right, we’re going to make sure we can’t hear any blood flow and then record those values, when we first start hearing, the flow will record the higher value of either lower extremity, you can record it for both right and the left leg, but odds are good that they should be relatively similar, right? Peripheral vascular diseases. Yeah, complications associated with like fatty plaque formations in the peripheral vasculature and so you know, to have a bias specifically in one location over the other extremity is pretty unlikely. So record that. The second page has a nice schematic of what’s normal, what’s abnormal, when should we be, like very concerned about this versus are you kind of getting close to, to experiencing some, some risks associated, so I hope it’s gonna be useful for for the clinicians, just as a quick, easy way to, you know, you got a patient coming in, that’s having maybe leg pain with walking after a couple of minutes or something like that, and it hasn’t been screened for this or diagnosed with PVD great one to pull out and kind of be first line of defense, I suppose for? Yeah, for for your patients.
Shweta Subramani 13:26
Cool. Um, I feel like I have still seen like clinicians use like stethoscope too because doppler is not that easily available. So I was just thinking, how reliable it is versus you know, using like an actual Doppler.
Troy Adam 13:43
Yeah, you know, I can’t speak to how specific the air is or the magnitude of that air, but I do think it’s actually relatively significant. So I’m not going to tell you to, you know, if you’re worried about it, and you don’t have a Doppler, you know, maybe check it out. But I don’t know, you would really have to use your own clinical judgment on how much you really value the results of that. I will say one thing I feel like a lot more clinics with, you know, kind of with one of the new PT crazes have blood flow restriction, there’s a lot of protocol related to yaa, there’s Dopplers that you get if you have a BFR blood flow restriction cuff. So I feel like they’re a little bit more accessible than they maybe were five or 10 years ago. But yeah, either way, it’s not they’re not necessarily cheap. You know, if you’re gonna buy one, they’re probably you know, maybe three, three to $500 is what I would expect. So, yeah, cheaper or more expensive than then your stethoscope. Yeah. I mean, yeah, but I would I guess I would caution folks to have using a stethoscope alone.
Ross Eckstein 15:00
You may as well just buy it with BFR set, because I think that for our clinic, we got it with the BFR Set. I think it was only like 150. I think it was cheaper to buy it with a set. It was a better deal. Yeah. There you go.
Shweta Subramani 15:15
I had no idea about that. Thank you for bringing that up. But like you said, like possibly like if they’re really meant to be a part. then ya that makes sense. For a clinic wise, 150 bucks that seems a little more reasonable. So yeah,
Troy Adam 15:28
yeah, yeah, sure.
Shweta Subramani 15:31
Awesome. We’ll move on to our next resource. This is a nice little two page handout about Heart Rate Variability Monitoring. So I will let Ross talk about it. Ross, can you tell us a little bit about this?
Ross Eckstein 15:46
Yeah. So this resource is probably it’s more with the clinician in mind, it’s unless you have a really fitness minded clients, like someone who does a lot of CrossFit, I think that’s getting more popular among that community to monitor heart rate variability. So they might find it useful as well. But heart rate variability is essentially a measurement of parasympathetic nervous system activity. So every time your heart beats, even though we think of heart rate as being something really regular, there’s little millisecond differences in time between each beat. And if you have a lot of parasympathetic activity to the heart, you have a high variability in those beats. Whereas if you have a lot of stress and sympathetic activity, then it’s a more regular beat pattern. And so one way to kind of measure whether you’re getting into that kind of more recovery mode, that parasympathetic state where your body’s repairing, and regenerating and doing some of the things that we liked, before you stress it, again, there’s some research suggesting that heart rate variability can be a way to evaluate that. And so this piece kind of talks about what heart rate variability is, it goes into a little bit of what I just talked about, talking about the sympathetic and parasympathetic nervous systems, the role of stress with heart rate variability, how things like sleep deprivation, dehydration can play into heart rate variability.
Ross Eckstein 17:18
And it talks a little bit about different devices that you can use, you can get, there’s electrocardiography devices, where you actually hook on electrodes or you wear a chest strap, that’s not incredibly common. The The main benefit to that is you can use it during high intensity exercise, and it will be accurate, whereas the optical sensors are less accurate during high intensity exercise. For the purposes of measuring parasympathetic activity, it’s really the first thing in the morning or overnight measurements that are more important anyway. And so there’s actually some apps so I used an app for a while it was like 10 bucks or something where it would basically wake up, you put your finger over your camera light, and it’ll measure your heart rate variability over a five minute period. And so then you can consistently so long as you so you have to do it the same time a day, same position, try to keep everything as consistent as you can. And then you can kind of see what your heart rate variability is, and measure changes with time. And there’s also, as technology advances, there’s now devices, I know there’s a ring, I can’t remember the brand name for it. But it’s kind of like a Fitbit that goes on your ring, ring finger. But basically, it can measure your overnight heart rate variability as well, which we’ll talk about in my article review. But overnight, is typically more accurate compared to first thing in the morning measurements, if you can advance if you have access to that.
Ross Eckstein 18:59
So like I said, The main disadvantage of the optical sensors is they aren’t very useful when you’re exercising. And then it talks a little bit about how to determine your heart rate variability. And so someone could look at this and very easily figured out you know how to how to do that which I just touched on, and how you should do it at least three or four days a week, and how you can look up data so you can compare your heart rate variability to other people’s heart rate variability, I don’t think that’s as useful for people generally more fit. Younger people have a higher heart rate variability than less fit or injured people. But a lot of that’s genetically driven and so I think it’s more useful to monitor your own trends with time so you can kind of see, you know, if your heart rate variability is decreasing and decreasing, decreasing over time, you know, okay, let’s take a look at is my sleep off and my dehydraterated, am I stressed, am I overtraining. And so it’s a way to give you a little feedback for that. And it talks a little bit about the different measures for heart rate variability. The main one to pay attention to is the root mean square of standard differences. Don’t ask me to calculate that. But basically, it’s the most widely used measurement of heart rate variability, there’s dozens of other ones, but they didn’t seem as practically useful. So that’s typically the main number that you look at when you measure your heart rate variability. So yeah, that’s basically that piece.
Troy Adam 20:45
Ross, I got a, I got a question for you, so yeah, how do I guess how does this how do you use this clinically? Is this something that you’re using relative? I mean, the thing that comes to my mind, I haven’t really actually heard about this before. This is the first time I’ve really heard about heart rate variability. Is this something that you would use similar to like a resting heart rate from? From like, a? Yeah, a fitness perspective, in terms of, yeah, yeah, how fit you are, or
Ross Eckstein 21:16
I think clinically, it would be more interesting, probably to more athletic clients. So people like status, post ACL, people like that, who really want to monitor their training, as they’re ramping up to get back into more intense exercise, I have thought about and incorporating this with some of the sicker populations that we see, the hardest thing, I guess, would be compliance, you know, I don’t know how compliant with people would be. In my clinic, it’s not a very tech savvy population, most of the people I see are over the age of 60. And so I don’t use it a lot in my population, you know the population, I see, I think it would be more something like if you have a pretty athletic population, or a population who’s very tech savvy and interested in knowing about their training status. Runners, for sure, could benefit from this because it gives you an idea of whether you’re overtraining or not. But it’s something that I would probably not measure in the clinic, it’d be something more I teach them to measure themselves, and then be somebody that they could then keep track of, maybe bring their data to me, but it’s not like I’m gonna measure it in clinic, because that wouldn’t be a useful measurement anyway, because you want to get it first thing in the morning when you’re pretty relaxed if that makes sense.
Troy Adam 22:39
Sure, great. Yeah. Awesome.
Shweta Subramani 22:43
Ross I am actually curious, since you said that it has to be first thing in the morning. So there’s like, because you mentioned that the it can be at a consistent time, I was curious if it has to has to be strictly the first thing in the morning or like can it be later? Like, if you see a patient consistently at a certain time of the day, are you still okay to like, do that for them? If that is something that might be beneficial? Because, honestly, when you talked about this, like the first thing that I could think of is I was reading a conversation about post COVID patients and a lot of them developing POTS. That is like a big thing that goes on. I mean, with POTS like heart rate is what is like jumping up with the change in position. So that’s why I was curious, like, Okay, is there a way to like apply this resource to that kind of population?
Ross Eckstein 23:32
You know, that’s an interesting thought. And I actually haven’t really looked into, you know, how Heart Rate Variability plays into POTS? I would almost wonder if they Well, I don’t know, that’s interesting. I don’t know if they would have more variability, because but yeah, that’s a very good question. And I’m not sure I guess if I answered you, I don’t know if you’d want to be doing it in clinic. Still, like I said, just because there is that, that variability day to day, and a lot of times people have different appointment times, and you know, if they’re running around and doing groceries before versus whether they come straight to your clinic, or they sit in for 15 minutes before you do it. And so, it’s an interesting idea, and something that, you know, that might be worth looking into the research and see if there’s any anything out there on that for POTS.
Shweta Subramani 24:20
Yeah. Yeah, absolutely. Like even like, even if it is not like, you know, from on a day to day basis, like even if it is something that’s that you’re doing as during your session, like measuring people or something like that, with each change in position or with each activity. So I’m just curious. Yeah. Like, I haven’t researched all that much into POTS either. But I just thought there was an interesting conversation that I was reading about, as far as seeing a lot of POTS and post COVID people and actually, like even therapists, who have recovered from COVID have been patients with POTS. That’s where I was like, Okay, maybe if If there’s any way that you know that I can, we can possibly apply this, that would be good.
Ross Eckstein 25:04
Well, if someone if someone had a baseline, I suppose it would also be interesting to see pre COVID. You know what their heart rate variability looked like after COVID? And how long it took to get back to, I guess, their pre-COVID baseline. But for that, you would need to have that baseline. I guess it’s the disadvantage to but yeah, it was interesting, interesting points.
Shweta Subramani 25:28
Okay, well, since our research, reviews are mostly tied to our resources, I know that this is a very interesting article coming up, on Reliability and Sensitivity of Nocturnal Heart Rate and Heart Rate Variability Monitoring: Individual Responses to Training load, which is related to your heart rate variability article, so I’ll let you talk about it Ross.
Ross Eckstein 25:50
Yeah, so this study, I think it kind of piggybacked off of a randomized control trial. So they were analyzing data and runners who had their heart rate variability measured. And it was in response to low intensity exercise that was done very consistently a certain time of day. And then they were looking at whether your full night or four hour, so first four hours of the night, full night or first thing in the morning, heart rate variability, monitoring was most accurate for detecting changes in response to those training loads. And they found that the full night and for first four hours of the night were both very good and equally good, really. And both were better than the first thing in the morning measures.
Ross Eckstein 26:39
And then they found that the high intensity training, so that’s something I forgot to touch on at the other piece, the high intensity. Anytime you do a really high intensity training session, there’s kind of a perturbation in your heart rate variability that lasts for a longer period of time compared to low intensity. So typically, when you do high intensity exercise, you can expect to have decreased heart rate variability, and more sympathetic nervous system activity for the first 48 hours or so. And with low intensity, it only typically is affected for more like 24 hours, which is essentially what they found with this study, as well. But essentially, they just, the general take home point from this is if you do have access to overnight monitoring, if you’re wanting to do this, that’s better than first thing in the morning. And they still don’t, you know, completely have nailed down, like, how much you know, should your heart rate variability get back to completely normal before you train, again, some of that some of those answers still need to be some of those questions still need to be answered. So. So yeah, it was kind of an interesting study, just kind of looking at the accuracy of different measures for heart rate variability.
Shweta Subramani 27:52
Great, thank you so much for your touching on that. And I like, Troy mentioned, I never knew much about this either. So this was quite eye opening for me too. So I’m definitely gonna go look into this.
Ross Eckstein 28:03
Yeah, it’s very interesting, for sure.
Shweta Subramani 28:06
Cool. So moving on. Our next resource is a nice one page handout about symptoms of differentiation and difference, I’m sorry, Symptoms and Differentiation of Leg Pain. Since this resource was created by Troy, I will let Troy talk about this.
Troy Adam 28:24
Yeah, great. So So yeah, you nailed it. It’s, this is really meant to be a quick and easy differentiation of some common pathologies, I suppose associated with with leg pain or lower extremity pain. So, you know, I think this this handout is probably, I think, maybe serves kind of two different kind of populations in terms of clinicians and patients and things like that, I think, I think this is helpful for the newer clinician, probably maybe somebody that’s, that’s kind of just just getting started or new to an outpatient type setting or new to kind of differential diagnoses, specifically, that and I think also for the patient that is maybe investigating things on their own to some degree, right? Or maybe a consultation that comes in or somebody that just has some quick questions. This can be a nice resource. It’s very easy to read, for both medical professionals but I also think lay lay persons as well.
Troy Adam 29:31
So it really talks about pretty much for four different things. So vascular claudication, meaning there’s not enough oxygen ultimately getting to the legs, which is causing pain. It’s talking about neurogenic pain as well. So this is driven from often, in this case, really nerve root compression or compression on a peripheral nerve. Peripheral neuropathy, which is really damage to those peripheral nerves as well. That’s, that’s, yeah, we’ll talk about the specifics of it. And then Restless Leg Syndrome. So those are the four different diagnoses that yeah, that it goes into. So vascular claudication, what you’re really looking for here more than anything else is, it’s often bilateral in nature. So these other ones Restless Leg Syndrome, you know, you can have some bilateral pain in that. Peripheral neuropathy and neurogenic claudication, they can have bilateral symptoms too but this vascular claudication is often both legs, it’s often kind of a burning type sensation. That’s, yeah, that can be pretty uncomfortable and it normally occurs after a little bit of exercise. So this isn’t something that someone experiences when they’re resting right. Rest is going to often decrease the symptoms associated with this. We talked about Ankle Brachial Index earlier. Vascular claudication would be a symptom of peripheral vascular disease, which again, would be indicative or would be associated with specific ABI values. So if there’s plaque and, and fatty deposits in the extremities, there’s enough blood getting into those muscles, no pain, when I’m just kind of feet up and relaxing. Maybe even when I walk from, you know, from one end of my house to the other end, maybe I still will do okay with that the demands on my legs aren’t that high, but maybe going out for a walk around the block or to the mailbox or something that’s a little bit farther away, I start to experience those symptoms come back. Now rest, the oxygen demand decreases on my legs, or on those on those muscles, and my pain starts to resolve. So it talks about the description of what it is, the signs and symptoms, the location of those symptoms, what aggravates it, what makes it feel better, and then the cause kind of the pathology as well as is, you know, kind of who’s likely to be experiencing these things.
Troy Adam 32:12
Neurogenic claudication, this is something that I that I think a lot of people are actually pretty familiar with, right? This is this is your, your patient that reports, you know, I have my back’s bad and I’m having pain that’s going down one side of my leg, or I’m having pain, maybe just going down the side of my leg and they don’t make an association with the back. This is normally you know, it can be tingling, also burning sharp numbness, that kind of sensation. But in general, you’re not going to see, you’re not going to see things like you’re not going to see things like color changes that you might in vascular claudication you’re going to see discomfort that’s maybe not associated with activity, but could be associated with position. So right if I’m stressing the lumbar spine in some way, you know, we could be causing compression on some of those nerves and yeah, causing discomfort. Peripheral neuropathies, so this is often more associated with some other condition, right? Peripheral Neuropathy is is, you know, the most common thing that people probably think of is diabetes mellitus. Right? The other common ones would be like I see several, quite a few folks actually post chemotherapy that will sometimes have neuropathy in their extremities. HIV can cause neuropathy and parasthesias. This is yeah, this is pain or and or numbness often is what it turns into. In the legs. It’s normally in a stalking glove kind of pattern, meaning it doesn’t follow those dermatomal patterns, but it’s rather, you know, the, everything distal to a certain point on the on the leg, it would affect distally before it would affect proximately as well. And then Restless Leg Syndrome. Yeah, so this is this is discomfort. Most people experienced this moreso in the evenings in moments of stillness than they do actually, with with moving around. But it’s yeah, it’s pain that can last. You know, it’s pretty highly variable in terms of how much discomfort folks have with this. There’s been a couple of studies that show that you know, caffeine can can cause some of these, this discomfort so potentially cutting out some of that can maybe be helpful. But yeah, it’s about symptom reduction, medication management, diet management, probably more than musculoskeletal kind of treatment approaches.
Shweta Subramani 35:09
Great, thank you Troy. All right, moving on. Our next resource is Dry Needling for Lateral Epicondylitis. And it’s a neat two page handout, which actually has some very informative pictures about dry needling. So since Ross was the one who produced this handout, I’ll have Ross talk about it a little bit. Off to you Ross.
Ross Eckstein 35:37
Yeah. So the orthopedic section of the American Physical Therapy Association released clinical practice guidelines for lateral epicondylitis I believe in December pretty recently. And one of the there was no no single treatment that had grade A evidence, meaning a preponderance of high quality, randomized controlled trials. And there were several treatments that had grade B evidence, meaning that there was at least one high quality randomized controlled trial to support it or a preponderance of lower level studies. And one thing that they suggested might be helpful is dry needling. And something I took, I’ve taken some interest in because there’s so many different types of needling techniques for lateral epicondylopathy that you see in the research. And so I thought I would talk about some that have shown benefit within the research and then also talked about some of the evidence for dry needling.
Ross Eckstein 36:40
So the first section kind of talks, it’s mostly, this was purely geared towards clinician clinicians, by the way, but the first section talks about, you know, the evidence for dry needling compared to some other treatments, so dry needling compared to corticosteroids. Typically, dry needling actually outperforms corticosteroids in the long term. Granted, corticosteroids we know break down tissue. So most things will outperform corticosteroids keep that in mind. And then compared to some of the fancier regenerative medicine techniques, like platelet rich plasma, dry needling is equally effective, and it’s a lot cheaper. And so, especially because with lateral epicondylopathy, the traditional isotonic loading that we use for a lot of tendinopathies does not seem to be quite as much of a slam dunk as it is for for lateral epicondylitis. So having some other treatment options can be helpful. So one other study that I thought was interesting is they did ultrasound guided dry needling, where they targeted the extensor tendons, the areas of tendinosis, the idea is you’re taking a chronic injury, turning it into a more acute injury so that your body actually addresses it and tries to heal. And they found that the dry needling was just as effective as open release surgery. And so it’s kind of interesting, and still research developing on all of that.
Ross Eckstein 38:07
So I aligned three protocols that can be used for dry needling. So I talked about a and I also put in there that this isn’t supposed to really replace training in dry needling. So you want to have training in dry needling. And if you do ultrasound guided dry needling, then you also want training in ultrasound imaging before you do it. But this can just give you some ideas as to what has worked in the research. So I talked about the muscular technique, which is, was based on a study that was actually discussed last month, where they were comparing it to, percutaneous electrolysis, the percutaneous electrolysis worked better, but this still provided moderate pain relief at a 25% improvements and three quarters of people after treatment. And so it outlines how to kind of needle the supinator and the common extensors for that and then it talks about one study that used the tendon technique. It talks about the dosage that was used in one trial. This was the study that was comparing it to corticosteroid injections and finding that the tendon needling more effective than the current corticosteroid injection. And then the last one talks a little bit about the study that compared the ultrasound guided needling to open release surgery and that was dose just one treatment. And at I think it was 81% of the people who had had good results and reduced pain after having it done. In that study, they used a larger needle, so I talked a little bit about how you would want to dose, since in PT we are using a monofilament needle, it’s about three times smaller than the needle they used in the study. And so you’d have to do probably three times as many passes if you wanted to have the same relative dose to the tendon. And so it kind of outlines how you would do that. So yeah, that’s that piece.
Shweta Subramani 40:18
Yeah, I agree. I think the pictures are a good refresher for people who have done dry needling or you know, taken courses or certified, but then they have something to look at in case. They’re looking for that placement, that visual feedback. And it’s, it’s a great handout to show patients to, like help them understand that this is what I’m going to be doing. And this is how it’s going to look and things like that. Give them more prep. I think that’s like, visually, it’s very appealing.
Ross Eckstein 40:48
Yeah, absolutely. And it gives you some information, you know, as far as how frequently they did and some of these trials and whether they’re left in place, or twisted or things like that, as well.
Shweta Subramani 41:00
Absolutely. Great. Well, now we’re good. Since we’ve been talking a lot about our resources, we always want to talk wrap up with something like a case study to show that how we can use the other resources in our access pass library, as well as discuss cases from different perspectives. So the case that we’re going to be talking about today is based loosely based on a patient that I was working with, until recently. A 70 year old male with Parkinson’s disease, living with his spouse in a single level home, loves to play golf with friends, and wants to get back to it, he has been having a lot of difficulty with movement because of an increase in his frequency of freezing episodes and he is requiring increased time to move after freezing. So based on this case, the handout that I felt was appropriate. And this is something that I shared with my patient as well was How to Stop Freezing with Parkinson’s disease.
Shweta Subramani 42:08
Now, because this patient was so frustrated with like his freezing episodes increasing and it was really impacting how he was trying to play golf and how much he really enjoyed golf, because that was like his only means of like, letting out all the frustration from Parkinson’s. So when I discussed this handout with the patient, and with his wife, he actually mentioned, oh, I do enjoy music, and I never really realized that that will be something that will be helpful with my freezing. So maybe I’ll give that a try. But like, music has been helpful to a lot of patients with Parkinson’s disease in general. But other than that, I feel like marching, shifting your weight from side to side, some of the really useful strategies from this handout, even stepping, imagining stepping over a line or doing those small movements, not just in your lower extremity, but also in your upper extremity, your head turns or your shoulder movements or body movements to just kind of slowly trying to get out of the freezing. I think it’s been very helpful for my patient. And I know that these are strategies that could be used by a lot of patients with Parkinson’s disease. Like if one doesn’t work out, there are many other options that you can still try. So that’s about that. And based on my case study, Ross came up with one of the resources from our access pass library as well. It’s called Home Exercise Tips for People with Parkinson’s. I’m going to let Ross talk about that.
Ross Eckstein 43:44
Yeah, I see some Parkinson’s disease at our clinic and a lot of times, we’re focused in clinic on kind of specific things, we don’t always have time to kind of go into, you know, different stretches and things, especially with 40 minute appointments. A lot of times, it’s like your big training and balanced training takes up a portion of the day. And you don’t always have time to get into some of these things. And so, I kind of liked a lot of the visuals with this is where it’s like showing different stretches that you can do to improve mobility since a lot of people with Parkinson’s tend to get pretty stiff through their hips and back talks about general strength training guidelines that can be helpful to kind of reinforce some of what we tell them in the clinic goes into functional training, and then talks about cardio respiratory training as well which, again, that’s not always something we have time to focus on as much and so I kind of thought it’s a nice adjunct to some of the treatment we do in clinic for Parkinson’s.
Shweta Subramani 44:53
Great. And again, based on my case study, we had Troy pick out his favorite resource too from our access pass library. And this one is called Evidence Based Practice for Individuals with Parkinson’s disease. It’s a neat little handout, and I’m going to have Troy talk about it.
Troy Adam 45:14
Yeah, great. So so this handout is I mean, really, it’s kind of part of a series. There’s a few different handouts on a few different diagnoses. But I pulled this one out, is what yeah, which is for individuals with Parkinson’s disease, really, it’s for you as a clinician. This is a dry one. But this is one that lives on my bulletin board in front of my computer, when I’m writing goals. One of my least favorite things to do is look up MDCs and MCIDs to be able to write evidence based goals for my patients with different diagnoses. Right? I work with a lot of folks with neurologic impairment, Parkinson’s disease being one of them. So things like you know, if I’m trying to improve community ambulation, I do a lot of six minute walk tests. But guess what, it’s not the same for somebody with Parkinson’s disease versus vestibular disorders or versus, you know, folks with stroke or things like that. So I’m always going back and you know, finding, okay, is this an actual meaningful change for this patient? Based on their diagnosis or not? That’s what this sheet is for, and others like it for other diagnoses. So it goes through, yes, there’s a table with with a variety of different objective outcome measures that that are easily performed in the clinic, and then talks about what exactly you need to be able to do that I really tried to pretty much use assessments that are accessible or evidence based, obviously, and that are free. You know, some, some high quality assessments are also cost money. We don’t have any of those on there on this one. But you can go through it, you can look up, not only is the improvement that they made, evidence based, and you can also kind of base it off of what Hoehn and yahr stage they’re in. So is this outcome measure actually even appropriate and applicable for the level of disability that my patient is experiencing at this phase and in their disease process. So yeah, love, love the resources like this is just a quick, easy thing for me to write up goals.
Shweta Subramani 47:32
I found this really cool Troy, because, like, this gave me an idea that we could actually even make like tables, very specific to different diagnosis. And just like this, it could be very handy. As far as you know, like, again, like you mentioned, like writing goals and looking at measures and you have everything all in one place. And you don’t really have to wait to like, look it up, or this is something that you can even show the patients that, like, this is what I’m doing. And this is how effective it is. So when we actually look for like change, and you kind of change over a period of time, this is what we’re aiming at. And things like I think that gives them a good visual too.
Troy Adam 48:09
Yeah, absolutely. And and like you mentioned, you know, helpful for other diagnoses, you know, we’ve got a few on there. They’re all more neurologic diagnoses in general. But yeah, I think they’re helpful ones.
Shweta Subramani 48:26
So before we wrap up today, I do want to mention that there were some other resources that were added to our library that you all might be interested in. Like our OT, content team added a resource on Abdominal precautions. It’s a neat little handout again, which has like different positions that you can adopt with the abdominal maintaining your abdominal precautions, and also has, like, small four point table, which tells you like what you need to follow in you are following abdominal precautions and trying to change positions. So do check that out. We also had another cool resource from our SLP, medical SLP team on the Safety Features of an Apple Watch. It has a nice pros and cons table. And it talks all about fall detection, emergency services and GPS tracking as far as Apple Watch is concerned. And I think that like a lot of our patients who are really getting into technology, would find this very helpful. So do check that out if that’s something that you would love to share with your patients. Okay, so I just wanted to say thank you to Ross and Troy for again, coming and talking about the resources and ways that we can apply this in our clinic. And to all of our listeners and viewers, Thank you so much for hanging out with us. We will be back with another therapy insights resource roadmap show. All you therapists out there, thank you so much for making therapy informative empowering and person centered. See you next time.